Module 4 (a) Menopause

Question 1

Menopause Info

Answer 1

1. A NORMAL life event that every woman will experience if she lives past age 50
   - Average menopause age is 52.54 years
2. Most American women will spend nearly one third of their lives in the postmenopausal period

Question 2

Menopause Definitions

Answer 2

1. Menopause — The permanent decline of estrogen and progesterone levels and 12 months of amenorrhea in a woman with a uterus and ovaries
2. Induced Menopause — Surgical removal of both ovaries, with or without removal of the uterus
3. Pre-Menopause — The entire reproductive time frame
4. Peri-Menopause — First stage of menopause: Translated as around the end of menstruation — Typically lasts 4-8 years
5. Post-menopause — Categorized by the remainder of a woman’s life after her final period
6. Premature Menopause — Cessation of menstruation in women younger than 40

Question 3

Menopause Physiology

Answer 3

1. Characterized by ovarian failure —Peri-menopause phase has significant decrease in the number of ovarian follicles with remaining follicles responding poorly to FSH and LH
2. Follicular development declines
3. Estrogen and progesterone Decrease
4. FSH increases
5. Menstrual cycles become irregular initially and the cease altogether

Question 4

Menopause Clinical Presentation

Answer 4

1. Vasomotor Sx’s (Hot flashes)
2. Urogenital atrophy — Vaginal dryness, urinary incontinence, pelvic floor dysfunction
3. Bone loss
4. Mood changes and irritability
5. Poor sleep and decrease libido
6. Dry skin and weight gain

Question 5

Peri-menopausal Women

Answer 5

1. Peri-menopausal women are at RISK for unplanned pregnancy
2. Oral contraceptives may be used to manage irregular cycles
3. HRT is NOT strong enough to control bleeding

Question 6

Menopause — Vasomotor Sx’s

Answer 6

1. Hot flashes — Transient, sudden, sensation of intense heat often described as “from the inside out”
2. Night sweats — Hot flashes that occur during sleep
3. Frequency can be daily, hourly or infrequent
4. Time frame is usually 3-5 years but can last for the remainder of a woman’s life
5. Can be triggered by alcohol, caffeine, spicy foods, stress — vasomotor Sx’s can increase anxiety and cause palpitations

Question 7

Surgical Menopause and Vasomotor Sx’s

Answer 7

1. Vasomotor Sx’s can be MORE severe and last longer after surgical menopause

Question 8

Vasomotor Sx Treatment

Answer 8

1. Combined HRT (estrogen & progesterone) or estrogen replacement Therapy ERT
   - Combo should be used w/ women with intact uterus
2. Venlafaxine, Gabapentin, Clonidine, and Paroxetine also help with controlling vasomotor Sx’s

Question 9

Menopause Genitourinary Sx’s

Answer 9

1. Vaginal dryness — discomfort w/ intercourse is a common complaint
   - As estrogen (estradiol) levels drop, vaginal blood flow and cervical/vaginal secretions decrease
2. Vulvar and vaginal tissue becomes thinner, paler, and drier w/ loss of elasticity
3. Shortening and narrowing of vaginal canal and introitus
4. Opportunistic vaginal infections such as bacterial Vaginosis and yeast can occur secondary to a drop in vaginal pH >4

Question 10

Treatment of Genitourinary Sx’s

Answer 10

1. Topical Estrogen improves:
   - Vaginal dryness
   - Urinary incontinence
   - Urinary urgency

Question 11

OTC options for Vaginal Dryness

Answer 11

1. Lubricants — Ex: Astroglide, KY, Sliquid
2. Vaginal Moisturizers — Ex: KY, Liquibeads, Replens
3. Coconut Oil

Question 12

Menopause Bone Mineral Loss

Answer 12

1. Estrogen deficiency leads to:
   -Increased osteoclasts activity in bones
   -Decreased bone matrix
   Decreased deposition of bone calcium and phosphate
2. Can lead to osteoporosis w/ HUGE risk for bone fracture — Ex: Hips and Vertebrae

Question 13

Bone Mineral Loss Screening

Answer 13

1. Average women, begin screening at age 65 and repeat every 2 years
2. Adequate intake of Calcium is 1200mg/day taken in divided dose of 600 mg BID
3. Adequate intake of vitamin D 800-1000 IU/day in pt’s >50 — Screen low Vit D annually
   - Ir Vit D is <20ng/ml, give 50,000 unites of D3 weekly
4. Recommend weight bearing activities
5. Counsel on how to avoid falls
6. Avoid tobacco and limit alcohol consumption to fewer than 2 drinks per day

Question 14

Medications for Osteoporosis

Answer 14

Ex: Fosamax, Boniva, Reclast

1. Stomach upset is VERY common
2. Must be taken on an empty stomach and AVOID eating or drinking for 30-60 minutes
3. Patients must NOT lie down or bend over for 30-60 minutes in order to avoid medication reflux

Question 15

Menopausal Hormonal Treatment

Answer 15

1. ERT — Estrogen Replacement Therapy
   - Appropriate for women WITHOUT an intact uterus ONLY **
   - Giving ERT to woman w/ an intact uterus INCREASES risk for endometrial hyperplasia and adenocarcinoma
2. HRT — Hormone Replacement Therapy
   - Combination of both estrogen and progesterone for women WITH an intact Uterus
   - Added progesterone protects lining of the uterus

Question 16

HRT and ERT Treatment

Answer 16

1. HRT and ERT are the MOST effective Tx’s for vasomotor Sx’s
2. Tx should be individualized
3. Longer duration of ERT is safer than HRT
4. Vaginal estrogens work best for Genitourinary Sx’s
5. For women >60 or more than 10 years from their last menses, there is MORE RISK than benefit

Question 17

ERT Info

Answer 17

1. Topical and oral preparation of Estradiol is preferred method —Estradiol is structurally identical to main estrogen from ovaries**
2. Oral estrogen should be avoided in women w/ hypertriglyceridemia, active gall bladder dz, or known thrombophilias such as factor V Leiden

Question 18

HRT (Combined Estrogen and Progestin)

Answer 18

1. ALL women with intact uterus need to take progestin with estrogen to prevent endometrial hyperplasia
2. FIRST CHOICE for progestin is oral micronized progesterone 200mg/day for 12 days of the month mimics normal Luteal phase
3. 100 mg/day given every day is sometimes prescribed
4. Advised to take progestin at bedtime, as it can cause somnolence
5. Some women cannot tolerate SE’s of progestins such as mood changes and bloating
6. Vaginal bleeding can occur in those who take cyclic progestins (12 days per month)

Question 19

HRT and ERT S/E’s

Answer 19

1. Uterine Bleeding HRT — Caused by progesterone
2. Breast tenderness (HRT and ERT) — Estrogen causes breast ducts to enlarge and progesterone causes milk glands to swell
3. Nausea (HRT) — Caused by progesterone
4. Headaches (HRT and ERT) — Caused by estrogen
5. Bloating or fluid retention in extremities (HRT) — Caused by progesterone
6. Mood changes (HRT and ERT) — Caused by Estrogen

Question 20

Compounded Bioidentical Hormone Therapy

Answer 20

1. Hormones most commonly compounded are estradiol, progesterone, testosterone, and DHEA
2. Popularity of these products cam after Women’s health initiative (2002)

Question 21

Women’s Health Initiative Study (WHI)

Answer 21

1. Breast Cancer risk w/ Estrogen and Progesterone Combination — INCREASED risk to 24% overall
2. Breast Cancer risk w/ estrogen alone — REDUCED risk of breast cancer
3. Estrogen and Progesterone Combo increased risk of heart disease by 80% in first year and 18% over entire Tx period
4. Estrogen alone showed NO difference in heart disease risk
5. Stroke and Blood clot risk increased 1/3 w/ both Combo and estrogen alone
6. Hip Fractures — decreased 33% in both combo and estrogen alone groups

Question 22

Menopause Management

Answer 22

1. Smoking Cessation
2. Weight bearing exercise
3. Maintaining a normal body weight —healthy diet, and vitamins and minerals
4. Limit alcohol
5. Reduce stress
6. Tx vasomotor Sx’s
7. Vaginal atrophy
8. Pharmacotherapy
   - Contraceptives therapy, hormones, non-hormonal therapy, bioidentical products

Question 23

Duration of Treatment for Menopause

Answer 23

1. Standard recommendation is for 5 years or less and typically NOT beyond 60 years
2. Avoid abrupt cessation** — Abrupt cessation can cause return of menopausal Sx’s